Heart, Lung and Circulation最新文献

Background: The Australian Cardiovascular (CVD) Disease Risk Calculator is used to estimate the individual risk of developing cardiovascular disease in the next 5 years. A new version was recently published (July 2023), with the aim of improving on the predictive performance of its predecessor (released in 2012). We present the findings of an external validation study comparing the predictive performance of the 2023 and 2012 Australian CVD risk calculators using data prospectively collected in the Hunter Community Study (HCS; NSW Australia), a longitudinal community-based cohort of people aged 55-85 years.

Methods: We compared the risk predicted by the two calculators to the observed 5-year events in the HCS, in terms of discrimination (using area under the receiver operator characteristic curve, AUROC), calibration (using observed vs expected, O/E, ratio), sensitivity, and specificity.

Results: Discrimination was very similar for the 2023 and 2012 calculators, with AUROC measured to be 0.71 95% confidence interval (CI; 0.66, 0.75) and 0.71 95% CI (0.67, 0.75), respectively. With the updated calculator, sensitivity was better in males, while specificity was better in females; there were also modest improvements in positive likelihood ratios for both males and females. The 2023 calculator was found to overpredict risk for males (O/E ratio 0.57, p<0.001), but was better calibrated for females (O/E ratio 1.02, p=0.46).

Conclusions: We conclude that the 2023 calculator provides some improvements in the prediction of CVD, specifically the positive likelihood ratios. However, there are also benefits in observing the old 2012 calculator for some purposes and specific population groups. We find that there is a need for a larger, nationwide cohort to allow further external validation of the 2023 Australian CVD Risk Calculator.

Background: Patients with end-stage heart failure experience a significant symptom burden that is often poorly controlled. Although palliative care can improve symptom management and reduce hospital admissions, many patients still die in acute care settings. The unpredictable course of end-stage heart failure complicates the identification of patients who would benefit from early palliative care referral. To address this challenge, an integrated cardiac supportive care service was developed to engage these patients early, optimise symptom control, and ensure timely access to palliative care.

Aim: The aim of this study is to document the symptom burden, using Patient-Reported Outcome Measures, for patients with end-stage heart failure on admission to the cardiac supportive care service.

Method: A prospective observational study was undertaken in a tertiary hospital service in Sydney, Australia between January 2020 and July 2022. Patients were included if they had a recent admission for heart failure or had heart failure with breathlessness or chest pain at rest or on minimal effort. The cardiac supportive care service, consisting of initial home visits and follow-up reviews conducted by a palliative care physician and cardiac nurse practitioner, collected information using the Dyspnoea-12 (D-12) Questionnaire and the Integrated Palliative Care Outcome Scale (IPOS). Symptom scores from these tools were analysed in relation to patient mortality, with Kaplan-Meier survival curves and Cox regression used to assess the association between symptom burden and time to death.

Results: A total of 114 patients were included in this study. Both the IPOS and D-12 scores indicated a substantial and clinically relevant symptom burden for this cohort of patients. High mean scores on the IPOS were observed for weakness (2.6, standard deviation [SD] 1.2), shortness of breath (2.6, SD 1.2), and sore/dry mouth (2.5, SD 1.3). Sore/dry mouth was the most frequent severe or overwhelming symptom (59%). The D-12 showed that descriptors of breathlessness most commonly rated as severe were "My breathing is exhausting" (40%), "My breathing is distressing" (39%), and "I feel short of breath" (38%). Patients with an IPOS score in the highest quartile had an elevated mortality risk. The survival of patients in this cohort was 17.1 months.

Conclusions: Patients with end-stage heart failure experience a substantial and frequently severe symptom burden, including breathlessness, dry mouth, and weakness. This study demonstrates the significant unmet need in this patient population and highlights the opportunity for integrated and proactive palliative care, delivered through a cardiac supportive care service. This model of care can optimise symptom management, facilitate advance care planning, and ensure timely referral to palliative care.

Background: The long-term mortality of patients undergoing linear ventriculoplasty (LVP) for ischaemic left ventricular aneurysm (LVA) varies. This study aimed to develop a risk prediction model for mortality after LVP.

Method: A total of 741 patients with an ischaemic anterior-wall LVA who underwent LVP between January 1999 and March 2021 at Fuwai Hospital were retrospectively enrolled, and 22 clinical features were assessed. The entire cohort was randomly grouped into training and validation cohorts in a ratio of 8:2. Backward stepwise elimination approach and the least absolute shrinkage and selection operator regression were used for feature selection. A nomogram was developed based on a multivariable Cox regression model. The performance of the model was evaluated using discrimination and calibration. Decision curve analysis was performed to test the clinical usefulness.

Results: The mean age was 58.6 (standard deviation 9.6) years, and 15.8% of the patients were female. The mean ejection fraction was 42.8% (8.5%). Coronary artery bypass grafting was performed in 93.4% of the patients. During a median follow-up of 60 months, 105 patients died. Eight features were selected and included in the multivariable Cox regression-based nomogram. The model achieved good calibration and discriminative ability as indicated by the concordance index (training 0.71; validation 0.77). Decision curve analysis showed the model had good clinical usefulness.

Conclusions: In this study, a nomogram with relatively good performance was developed to predict individualised long-term mortality after LVP in patients with an ischaemic anterior-wall LVA. However, external validation is needed.

Pressure-volume (PV) loop analysis remains the gold standard for studying cardiac physiology by offering a comprehensive analysis and quantitative assessment of the heart. The PV loop analysis uncovers the complex interplay between pressure and volume within the ventricle during each cardiac cycle and provide clinicians and researchers with invaluable insights into the efficiency and performance of the heart. By plotting ventricular pressure against ventricular volume, PV loops create a closed curve, signifying the dynamic changes occurring throughout the entire cardiac cycle. This review examines the importance of mastering the fundamentals of the PV loop and understanding valvular heart disease impacting the left heart.

Background: Atrial fibrillation (AF) significantly contributes to rising healthcare costs in Australia, with inpatient care accounting for most expenses. Recent literature has explored the use of a "wait-and-see" approach to managing patients presenting to emergency departments with primary AF given the high rate of spontaneous cardioversion (SCV), thereby avoiding invasive cardioversion and costly hospital admission. Limited adoption of this model of care may stem from challenges in identifying patients who truly need admission. To address this, predictive models for SCV are being explored. Our study aims to determine the accuracy threshold at which such models achieve cost savings by preventing unnecessary AF admissions.

Method: A decision-analytic model was used alongside Monte Carlo simulations to estimate the variability in cost per patient with changes in prediction model accuracy and expected rates of SCV. Estimated costs were derived from a sample of patients presenting to Flinders Medical Centre or Noarlunga Hospital, South Australia in 2022-2023 with primary AF.

Results: There were 669 admissions at Flinders Medical Centre or Noarlunga Hospital for primary AF in 2022-2023. SCV occurred in 240 (35.9%) cases, representing potentially avoidable admissions. The base case cost per admission was AUD$5,793.94, further increasing to $7,009.42 if interhospital transfer was required. The point at which cost benefit would be observed in our patient cohort was between 60% and 70% accuracy. There was an incremental reduction in cost in relation to increasing prediction model accuracy or population SCV rate.

Conclusions: Predicting SCV with an accuracy of 60%-70% in patients presenting with primary AF results in cost savings and reduced hospital bed utilisation through avoiding unnecessary admissions.

Aim: We sought to investigate the use of lipid-lowering therapy (LLT) and the attainment of low-density lipoprotein cholesterol (LDL-C) goals in patients with atherosclerotic cardiovascular disease (ASCVD) in Australian general practices. The study aimed to investigate the discrepancies between guideline recommendations and clinical practice.

Method: This retrospective study used electronic data from Australian general practitioners, extracted from IQVIA's "general practice electronic medical record" data set, covering the period from January 2010 to June 2022. Descriptive statistics examined the relationships between demographics, clinical characteristics, treatment patterns, adherence to LLT, and the achievement of guideline-recommended LDL-C goals, with data stratified by gender, age, and LDL-C levels.

Results: Of 13,644 patients with ASCVD identified, 64% of the patients with ASCVD were men, and the overall mean age was 70 years (±13.5 standard deviation). Only 51.9% of patients had a recorded LDL-C test at their most recent general practice physician visit. Of those tested, 60.5% and 50.6% had increased LDL-C levels >1.8 mmol/L and >2.0 mmol/L, respectively. Statin therapy was prescribed to n=11,100 (81.3%) of patients during the study period, but this fell to n=8,918 (65.4%) by the last consult. Of those on treatment at their last review, statin monotherapy was the most common (n=7,861, 57.6%), with a low use of combination therapies (n=1,004, 7.36%). At 1 year, 80.1% of patients on statin monotherapy were adherent (proportion of days covered ≥0.8), but this fell to 47.9% at 5 years. The use of non-high-intensity statins were associated with the highest persistence, being 47.5% adherent at 5 years. There were no significant differences in persistence between females and males nor across age categories <44, 44-65, and>65 years old.

Conclusions: The study highlights gaps in the management of ASCVD in Australian general practice, including the lack of monitoring of LDL-C levels, under-prescription of proven LLT, and increasingly poor adherence and persistence with LLT over time.

Catheter ablation has emerged as a pivotal therapeutic strategy for managing scar-related ventricular tachycardia (VT) in patients with structural heart disease (SHD). However, VT ablation can be complex and challenging because of the nature of VT circuit configurations and their interplay with the underlying SHD. This review outlines our systematic approach to VT ablation within the context of SHD, focusing on preprocedural assessment, procedural techniques, and postprocedural care. By adopting a systematic approach and leveraging technological advancements, successful VT ablation outcomes can be achieved in patients with SHD.